Özlem Pata TAJEV 2014

Pregestational DM approximately %1 of all pregnancies

Rapidly increasing incidence of type 2 pregestational DM

%90 of diabetes in pregnancy is gestational DM

Glucose Control

First Trimester:Prevention hypoglisemia, congenital malformation

Second- Third Trimester: Detailed Ultrasound and Fetal assestment

Delivery Time

Glysemic control preconceptional and early gestational days with

< HbA1C

o Congenital anomalies <%4)

o Spontaneous abortus ( %13,3-10.4 )

o Preterm labor

Diabets and Pregnancy Group

France 2003

Associated with increased fetal and neonatal risks

Associated risks

Spontaneous abortion As high as %17

Congenital malformation- X 4-10

Stillbirth-P. Mortality

X 5

Neonatal Mortality x15

Infant Mortality X 3

Macrosomia

Gestational DM % 20

Pre-existing DM % 35

Ekran Resmi 2014-05-01 07.56.32

TAJEV 2014

Determine accurate gestational age

Identified fetal anomalies

To rule out fetal growth abnormalities

Being avoidance of fetal deaths

Early detection of fetal compromise

Prevention of unnecessary premature birth

o Fetal limb, body and breathing movements correlate to maternal glucose concentration

o Low or failing levels of fetal movements are associated with abnormal CTGs and fetal distress similar to hypoxic fetus of non diabetic women

Roberts et al 1980

o Inexpensive easy to perform • Poorly define

• No aggreement as to instruction given to women

• 10 movements /2 h

Stiilbirth rate drop from 8.2 to 2.1 /1000 live

births

Moore et al AJOG 1989

o A reactive NST reassuring 99% survive for 7 days

o High false positive rate o %50 reactive < 28wks ,

85 % beyond 28-32wks o In DM 2 times/wks

Kersen et al

There was no significant difference identified in potentially preventable deaths

(RR 0.23, 95% CI 0.04 to 1.29, two studies, N = 469)

There is no clear evidence that antenatal CTG improves

perinatal outcome Cochrane Database 2012

Fetal demise and poor outcome have been reported hours after a normal trace

False negative CTG findings are more commonly reported in diabetic than in nondiabetic pregnancies

Shaxted EJ Obstet Gynecol 1981

26 women with type 1 DM in third trimester compared with uncomplicated pregnancies o 28-39 weeks cCTGs weekly

o 11.3 % showed absent episodes with the expected value of 0.8%

o Differences in the short term variation, basal heart rate,

frequency of fetal mavement, hearth rate acceleration. Correlation between FHR pattern and maternal glysemic

control Relevance of this to the risk of fetal demise has not

beeen determined o Tincello et al Br.J.Obstet Gynecol 2001

o Tincello et al J. Perinat Med. 1998

o BPP (Fetal breathing, movement, tone,

AFI) /30 minute

• 8-10 reassuring

• 6-7 reevalution with in day

• 0-4 suggest hypoxemia

oModified BPP (NST+AFI)

Twice weekly modified BPP was an effective method of fetal assesment to prevent stiilbirth with a rate of 1.4/1000

Kjos et al AJOG 1995

Good ppv (%95) at determining an APGAR score of >7 at 1 and 5 min. However poor predictive value and sensitivity for adverse fetal outcome .

Dicker et al. AJOG 1988

Diabetic Pregnancies have a higher false –negative rates than other high risk

pregnancies

oUmblical artery Doppler will be normal

oMCA Doppler redistrubition

oDuctus Venosus hypertrophic cardiomyopathy

With BPP there may be lowered high incidence false negative tests

Limitation in predictive power of many fetal monitoring methods and lack of RCT

Indivulized according to clinics and patients in various combinations

The frequency of iu deaths excluding congenital malformations 3.0/1000

Approximately 50 % after 36 weeks

Usually after 32 weeks

CEMACH Study 2002

CEMACH 2005

o Antenatal surveillance safely achieved with a

testing sequence that consists of twice

weekly NSTs backed up by BPS, CSTs.

• Golde et al AJOG 1984

o 4 deaths in 46 diabetic pregnancies when

interval was greater than 4 days

• Miller et al et al J Reprod

Medicine 1985

1,206 with type 1 diabetes and 342 with type 2 diabetes

Fetal death 4 times greater (RR

4.56 [95% CI 3.42, 6.07], p < 0.0001)

İnfant death nearly doubled (RR

1.86 [95% CI 1.00, 3.46], p = 0.046)

oStillbirth is correlated by glysemic control

o Perinatal asphyxia correlated by

• PA HT

• Smoking

• Fetal macrosomia

• Maternal hypoglisemi before delivery

FETAL SURVEİLLANCE İS REQUİRED WHEN THESE COMPLİCATİONS

ARE FOUND IN DİABETİC PREGNANCY

Birthweight Birthweight

Peri-conception HbA1c Pre-pregnancy care

Smoking Third-trimester HbA1c

Later gestation at first antenatal visit

Increasing maternal BMI

Prepregnancy nephropathy retinopathy

Longer maternal height

Glinianaia et al Diabetelogia 2012

Population based cohort study: n-1505

Histopathological changes o nRBCs

o Fibrinoid necrosis

o Villous immaturity

o Chorangiosis

Placental weight

Evers et al 2003

AGA-infants of diabetic women may be protected against hypoxemia

because of a relative high placental weight

Control Type I DM

n 36415 331

PAPP-A 1.01 0.86

Free Beta hcg 0.99 0.98

Significant inverse relationship between HbA1C and

PAPP-A

Madsen et al Acta Obstet Gynecol

2011l

o Increase in maternal obesity

o Lower incidence of maternal vascular complications

o Poorer control in advanced pregnancy weeks

Risk of Stillbirth

Risk of shoulder dystosia and

intrapartum asphyxia

Ratio Weight

5-23.1% 4000-4500

20-50% >4500

Wide range of sensitivities and specifities for identifying macrosomia

Serial USG may provide a more accurate estimation • Thung et all Clin. Obstet Gynecol 2013

Hammoud- Visser et alUOG 2013

Depends on types of Diabetes –associated risk factors and Glysemic

Control

o Concerning mode of delivery be initiated when fetal weight >4500

• ACOG

o May avaiable >4000g Thung et al. Clin. Obstet Gynecol

Gestational Age Fetal Testing

First Trimester Dating ultrasound

18-20 wks Detailed anatomic survey

22 wk Fetal echocardiography

Third trimester Serial Growth US

32 wk NST 2 times /wks ins requiring DM

38 wks Significant risk factor delivery

39-40 wk Deliver ins requiring DM

40 wk NST for Diet controlled DM

41 wk Deliver diet-controlled DM

Don’t Forget Case by Case Determination